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extra 2(not my notes) > Psychotic Disorders > Flashcards

Psychotic Disorders Flashcards

1
Q

Schizophrenia prevalence?

A

1% lifetime prevalence

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2
Q

Schizophrenia gender balance and peak onset?

A

M>F
20-28 in men
26-32 in women

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3
Q

Groups in which schizophrenia prevalence is increased?

A

Immigrants
If born from Jan to April in northern hemisphere
Low SES

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4
Q

Genetic factors in aetiology of schizophrenia?

A

50% risk with two schizophrenic parents

50% concordance in MZ twins

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5
Q

Neurochemical factors in aetiology of schizophrenia?

A

Dopamine Hypothesis
+ve symptoms from hyperdopaminergia in mesolimbic system, -ve symptoms from hypodopaminergia in mesocortical system.
Serotonin, glutamate, NA, Ach and GABA all implicated too.

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6
Q

Other aetiological factors in schizophrenia?

A
  • Environmental - winter births, viral infections, other CNS pathologies (neurosyphillis, encephalitis, temporal lobe epilepsy)
  • Life events - social exclusion, childhood trauma/abuse, migration, urban environment. (High expressed emotion = risk factor for relapse)
  • Substance misuse - cannabis (6x), amphetamines.
  • Perinatal trauma - hypoxia, maternal stress
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7
Q

Common presentations of schizophrenia?

A

Spouse/relative noticing withdrawn/bizarre behaviour, failure to achieve academic potential, presentation via criminal justice system, presentation following deliberate self-harm or suicide attempt, complaining to council/police on basis of delusional symptoms.

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8
Q

Positive symptoms of schizophrenia?

A

Hallucinations
Delusions (of control, influence or passivity)
Thought echo, insertion, withdrawal and broadcast

Are focus of drug treatment and are responsive. Acute phase.

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9
Q

Thought disordered symptoms of schizophrenia?

A

Disorgansied thinking/speech
Disorganised behaviour
Inappropriate affect.

Often detectable in prodromal phase.

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10
Q

Negative symptoms of schizophrenia?

A 
Affect blunt
Apathy
Avolition
Anergy
Anhedonia
Alogia (poverty of speech)
Asociality
Attentional Impairment

Continuum of normal traits, late feature, less responsive to treatment.

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11
Q

What are Scheider’s first rank symptoms?

A 
HALLUCINATIONS
- 3rd person commenting
- 3rd person discussing
- Thought echo
THOUGHTS
- Insertion
- Withdrawal
- Broadcase
OTHERS
- Delusional perceptions
- Somatic experiences
- Delusions of passivity (acts, impulses, affects)
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12
Q

Investigations for schizophrenia?

A 
Full physical examination
Serum and/or urine drug screen
Liver, renal and thyroid function tests
FBC
Fasting blood glucose (or HBA1C)

More specific investigations on a case-by-case basis.

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13
Q

Diagnostic criteria for schizophrenia?

A
  1. Characteristic symptoms (2 or more for a significant portion of time during 1-month period)
  2. Social/occupational dysfunction
  3. Continuous signs of disturbance for at least 6 weeks
  4. Schizoaffective/mood disorder exclusion
  5. Substance/general medical condition exclusion
  6. Relationship to a pervasive developmental disorder
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14
Q

Types of schizophrenia?

A

Paranoid = relatively stable, often paranoid delusions, accompanied by (usually auditory) hallucinations and perceptual disturbances.

Hebephrenic = affective changes prominent, delusions/hallucinations are fragmentary and fleeting. Behaviour irresponsible/unpredictable, mannerisms common. Tendency to social isolation and rapid development of negative symptoms.

Also CATATONIC, SIMPLE, UNDIFFERENTIATED.

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15
Q

Initial management of schizophrenia?

A

Refer all patients first presenting with psychotic symptoms in primary care to local community-based secondary mental health service – full assessment in secondary care, including assessment by psychiatrist. Care plan ASAP; include – crisis plan based on risk assessment (self-neglect, suicide, further mental deterioration), roles of primary and secondary care, key clinical contacts in case of emergency/impending crisis.

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16
Q

Biological management of schizophrenia?

A

2nd gen Antipsychotic drugs - Respiridone, Olanzapine, Clozapine, Amisulpride, Quetiapine.

Choice guided by side-effect profile and patient choice. Start one oral atypical at lowest effective dose

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17
Q

How long pharmacological treatment course for schizophrenia?

A

Continue >1-2 years, reduce slowly and monitor mental state. High rates of relapse if stopped early/suddenly.

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18
Q

What should be done before starting antipsychotics?

A

Bloods - FBC; U&E; LFT; RBS/HbA1c; Prolactin; Lipids. Physical – Weight; BP; Pulse. ECG (risk of prolonged QTc/arrhythmias).

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19
Q

What four types of effect do antipsychotics have?

A 
Dopaminergic
Prolactin
Anticholinergic
Anti-adrenergic
Antihistamine
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20
Q

Dopaminergic effects of antipsychotics?

A

Mesocortical/mesolimbic – behaviour (antipsychotic effects). Nigro-striatal – co-ordination of voluntary movements (extra-pyramidal). Tuberoinfundiular – prolactin secretion.
EPSE – Acute = parkinsonism, dystonia (treat with anticholinergics), akathisia (adjust dose). Chronic = tardive dyskinesia, choreoathetoid movement (more with 1st generation).

Prolactin – Amenorrhoea, galactorrhoea. (D2 receptor affects prolactin regulation).

21
Q

Anticholinergic effects of antipsychotics?

A

Dry mouth, blurred vision, constipation, urinary retention (can’t spit, pee, poop, see)

22
Q

Anti-adrenergic effects of antipsychotics?

A

Postural hypotension, sexual dysfunction

23
Q

Anti-histamine effects of antipsychotics?

A

Sedation, anti-emetic.

24
Q

Differences in side-effect profile of 1st and 2nd gen antipsychotics?

A

1st gen = higher risk of neurological side effects. 2nd gen = higher risk of metabolic side effects – hyperglycaemia, weight gain, dyslipidaemia.

25
Q

Clozapine?

A

Greater efficacy. NICE – offer when unresponsive to two different antipsychotics. Side effects = agranulocytosis (regular FBCs), myocarditis, weight gain, salivation, seizures, sedation.

26
Q

Psychological treatment of schizophrenia?

A

CBT – offer to all with schizophrenia. Doesn’t help reduce voices or delusions but helps reduce the distress they cause, and associated depression and anxiety. Helps develop individual understanding of disorder

27
Q

Social treatment of schizophrenia?

A
  • Family Intervention (FyT)/Carer Support – offer to families living with patient. Reduces HEE and relapses.
  • Arts Therapies – helps negative symptoms.
  • Physical care – adverse side-effects of medication - healthy eating/physical activity programme, interventions to address obesity/abnormal lipids/hyperglycaemia, advice RE smoking cessation.
    Do not routinely offer counselling, supportive psychotherapy, social skills training, adherence therapy.
28
Q

Prognosis of schizophrenia? Risk factors for relapse?

A

1/3 good, 1/3 bad, 1/3 intermediate. Risk factors for relapse = presence of persistent symptoms, poor compliance, lack of insight, substance use.

29
Q

Good/bad prognostic factors for schizophrenia?

A

Good prognostic factors = female, married, older age of onset, good pre-morbid intelligence and personality, family history of affective disorder, acute onset, affective symptoms, rapid and effective response to treatment.

Poor prognostic factors = male, single, early age onset, abnormal pre-morbid personality, FH schizophrenia, insidious onset, negative symptoms, delay in treatment, substance abuse.

30
Q

Lifetime prevalence of schizoaffective disorder?

A

Lifetime prevalence = 0.5-0.8%. Limited data available on gender and age differences.

31
Q

Presentation of schizoaffective disorder?

A

Has features of both affective disorder and schizophrenia which are present in approximately equal proportion.

32
Q

ICD-10 criteria for schizoaffective disorder?

A

Schizophrenic and affective symptoms simultaneously present and both equally prominent.
Excludes patients with separate episodes of schizophrenia and affective disorders and when episodes are in the context of substance use or other medical disorder.

33
Q

Management of schizoaffective disorder?

A

As for schizophrenia but treat manic or depressive symptoms as outlined in bipolar disorder.

34
Q

Prognosis of schizoaffective disorder?

A

Depressive symptoms more likely to signal a chronic course compared to manic presentations. Overall prognosis better than schizophrenia and worse than primary mood disorder.

35
Q

Epidemiology of delusional disorder

A

Relatively uncommon – point prevalence = 0.03%, lifetime risk 0.05-0.1%. Mean age onset = 40-45. M=F but delusional jealously more common in men and erotomania more common in women.

36
Q

Biological aetiology of delusional disorder?

A

Neurological lesions associated with temporal lobe, limbic system and basal ganglia are implicated in delusional syndromes. Prominent cortical damage often leads to simple, poorly formed, persecutory delusions. Lesions of G elicit less cognitive disturbance and more complex delusional content.
Excessive dopaminergic and reduced acetylcholinergic activity have been linked to formation of delusional symptoms.

37
Q

Psychological aetiology of delusional disorder?

A

Freud – delusions serve a defensive function, protecting patient from intraphysically unacceptable impulses through formation, projection and denial.
Cognitive psychology regards delusions as the result of cognitive defects where patients accept ideas with too little evidence for their conclusions; delusions as the result of attempting to find a rational basis for abnormal perceptual experiences.

38
Q

Social aetiology of delusional disorder?

A

Certain social situations may increase the chances of developing a delusional disorder. E.g. distrust and suspicion, social isolation, jealousy, lowered self-esteem, people seeing their own defects in others, rumination over meaning and motivation.

39
Q

Presentation of delusional disorder?

A

Patients present with circumscribed symptoms of non-bizarre delusions, but with absence of prominent delusions and no thought disorder, mood disorder, or significant flattening of affect. No identifiable organic basis.
ICD-10 specifies that symptoms should have been present for at least 3 months.

40
Q

Assessment of delusional disorder?

A

Clinical judgement necessary to distinguish delusions from over-valued ideas, especially when ideas expressed are not necessarily bizarre or culturally abnormal (and may actually have some basis in reality).

41
Q

Things to take into account in delusional disorder?

A
  • Degree of plausibility
  • Evidence of systemization, complexity and persistence
  • Impact of beliefs on behaviour
  • Allowing for possibility that they might be culturally sanctioned beliefs from one’s own
  • Observation of associated characteristics, including hallucinations
  • History of ‘morbid change’
  • Evidence of other risk factors
42
Q

Pathological (delusional) jealousy?

A

Patient holds the delusional belief that his or her partner is being unfaithful, and will go to great lengths to find evidence of this. AKA Othello syndrome. It is not the truth or otherwise of the delusional belief that is the essential quality; rather the fact that it is based on an incorrect reference about external reality. May result from a number of conditions. If no primary cause can be identified – treat with neuroleptic (chlorpromazine). If there is a risk of violence, may be best to recommend that the couple separate.

43
Q

Erotomania (de Clérambault’s Syndrome)?

A

Patient holds the delusional belief that someone else, usually of a higher social or professional status, or celebrity (someone ‘unattainable’) is in love with them, and may make repeated attempts to contact that person. Rejections may be seen as actually representing coded messages of love.

44
Q

Persecutory delusions?

A

Most common of delusional disorders. Patients believe they are being persecuted in various ways (being defrauded or plotted against).

45
Q

Cotard’s syndrome?

A

Nihilistic, delusional disorder in which the patient believes that he or she does not exist or is already dead. Can take a somatic form, with the patient believing that parts of their body do not exist. Can be secondary to very severe depression or organic disorder.

46
Q

Capgras syndrome?

A

Patient believes that a person who is familiar to them has been replaced by a double. Primary causes = schizophrenia, mood disorder and organic disorder

47
Q

Fregoli syndrome?

A

ery rare, in which patient believes that a familiar person, who is often believed to be the patient’s persecutor, has taken on different appearances. The patient ‘recognises’ this person in others who may look completely different from the actual other person.

48
Q

Folie á Deux?

A

When delusional disorder is shared by two or more people who are emotionally related. One has a genuine psychotic disorder and his/her delusional symptom is induced in the other person, who may be dependent on or less intelligent than the first. Geographical separation leads to recovery of those who are psychiatrically well.

extra 2(not my notes) (12 decks)

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